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1.  Medical physics aspects of cancer care in the Asia Pacific region: 2011 survey results 
Medical physicists are essential members of the radiation oncology team. Given the increasing complexity of radiotherapy delivery, it is important to ensure adequate training and staffing. The aim of the present study was to update a similar survey from 2008 and assess the situation of medical physicists in the large and diverse Asia Pacific region.
Between March and July 2011, a survey on profession and practice of radiation oncology medical physicists (ROMPs) in the Asia Pacific region was performed. The survey was sent to senior physicists in 22 countries. Replies were received from countries that collectively represent more than half of the world’s population. The survey questions explored five areas: education, staffing, work patterns including research and teaching, resources available, and job satisfaction.
Results and discussion:
Compared to a data from a similar survey conducted three years ago, the number of medical physicists in participating countries increased by 29% on average. This increase is similar to the increase in the number of linear accelerators, showing that previously identified staff shortages have yet to be substantially addressed. This is also highlighted by the fact that most ROMPs are expected to work overtime often and without adequate compensation. While job satisfaction has stayed similar compared to the previous survey, expectations for education and training have increased somewhat. This is in line with a trend towards certification of ROMPs.
As organisations such as the International Labour Organization (ILO) start to recognise medical physics as a profession, it is evident that despite some encouraging signs there is still a lot of work required towards establishing an adequately trained and resourced medical physics workforce in the Asia Pacific region.
PMCID: PMC3432256  PMID: 22970066
2.  A rare case of an appendiceal mass masquerading as a pelvic tumour and causing bilateral hydronephrosis 
Diagnosing acute appendicitis in children can be difficult due to atypical presenting symptoms. While there are reported cases of acute appendicitis or appendiceal masses causing unilateral hydronephrosis, bilateral hydronephrosis as a complication of appendiceal mass is very rare. We report a case of a child who presented with cardinal symptomatology associated with the urogenital tract. Ultrasound (US) investigation showed a pelvic mass causing bilateral hydronephrosis. An initial diagnosis of a pelvic teratoma was made based on the US and computed tomography (CT) scan findings. The final diagnosis of an appendiceal mass causing bilateral hydronephrosis was established intraoperatively.
PMCID: PMC3432257  PMID: 22970067
Appendiceal mass; bilateral hydronephrosis; pelvic teratoma; children
3.  Pelvic lipomatosis: US and CT diagnosis 
PMCID: PMC3432258  PMID: 22970068
4.  Effective connectivity between superior temporal gyrus and Heschl’s gyrus during white noise listening: linear versus non-linear models 
This fMRI study is about modelling the effective connectivity between Heschl’s gyrus (HG) and the superior temporal gyrus (STG) in human primary auditory cortices.
Materials & methods:
Ten healthy male participants were required to listen to white noise stimuli during functional magnetic resonance imaging (fMRI) scans. Statistical parametric mapping (SPM) was used to generate individual and group brain activation maps. For input region determination, two intrinsic connectivity models comprising bilateral HG and STG were constructed using dynamic causal modelling (DCM). The models were estimated and inferred using DCM while Bayesian Model Selection (BMS) for group studies was used for model comparison and selection. Based on the winning model, six linear and six non-linear causal models were derived and were again estimated, inferred, and compared to obtain a model that best represents the effective connectivity between HG and the STG, balancing accuracy and complexity.
Group results indicated significant asymmetrical activation (puncorr < 0.001) in bilateral HG and STG. Model comparison results showed strong evidence of STG as the input centre. The winning model is preferred by 6 out of 10 participants. The results were supported by BMS results for group studies with the expected posterior probability, r = 0.7830 and exceedance probability, ϕ = 0.9823. One-sample t-tests performed on connection values obtained from the winning model indicated that the valid connections for the winning model are the unidirectional parallel connections from STG to bilateral HG (p < 0.05). Subsequent model comparison between linear and non-linear models using BMS prefers non-linear connection (r = 0.9160, ϕ = 1.000) from which the connectivity between STG and the ipsi- and contralateral HG is gated by the activity in STG itself.
We are able to demonstrate that the effective connectivity between HG and STG while listening to white noise for the respective participants can be explained by a non-linear dynamic causal model with the activity in STG influencing the STG-HG connectivity non-linearly.
PMCID: PMC3432259  PMID: 22970069
fMRI; dynamic causal modelling (DCM); Bayesian Model Selection (BMS); non-linear DCM
5.  Quality assurance of TomoDirect treatment plans using I’mRT MatriXX 
To evaluate the performance of 2D-array I’mRT MatriXX for dose verification of TomoDirect treatment plans.
In this study, a 2D-array ion chamber device – the I’mRT MatriXX and Multicube Phantom from IBA – was used for dose verification of different TomoDirect plans. Pre-treatment megavoltage computed tomography (MVCT) was performed on the phantom setup for position correction. After the irradiation of treatment plans on the I’mRT MatriXX and Multicube Phantom, the measured doses of coronal planes were compared with those from the planning calculations for verification. The results were evaluated by comparing the absolute dose difference in the high dose region as well as the gamma analysis of the 2D-dose distributions on the coronal plane. The comparison was then repeated with the measured dose corrected for angular dependence of the MatriXX.
When angular dependence is taken into account, the passing rate of gamma analysis is over 90% for all measurements using the MatriXX. If there is no angular dependence correction, the passing rate of gamma analysis worsens for treatment plans with dose contribution from the rear. The passing rate can be as low as 53.55% in extreme cases, i.e. where all doses in the treatment plan are delivered from the rear.
It is important to correct the measured dose for angular dependence when verifying TomoDirect treatment plans using the MatriXX. If left uncorrected, a large dose discrepancy may be introduced to the verification results.
PMCID: PMC3432260  PMID: 22970070
6.  Fine needle aspiration of lung lesion: Lateral and transpectoral approach 
A 69 year-old man presented with an incidental finding on radiograph of a lesion in the left upper lobe. CT indicated it was likely to be a neoplasm and CT-guided FNA was requested. The lesion was located medial to the scapula so a creative approach was utilised to gain access to the lesion. This study discusses the approach used and why it reduced patient risk compared to a more conventional procedure. The sample was positive for neoplasm and there were no complications arising from the procedure.
PMCID: PMC3432221  PMID: 22970058
Fine needle aspiration (FNA); pneumothorax; lung lesion; biopsy; CT
7.  Multislice CT of the head and body routine scans: Are scanning protocols adjusted for paediatric patients? 
To investigate whether the multislice CT scanning protocols of head, chest and abdomen are adjusted according to patient’s age in paediatric patients.
Materials and Methods:
Multislice CT examination records of paediatric patients undergoing head, chest and abdomen scans from three public hospitals during a one-year period were retrospectively reviewed. Patients were categorised into the following age groups: under 4 years, 5–8 years, 9–12 years and 13–16 years, while the tube current was classified into the following ranges: < 49 mA, 50–99 mA, 100–149 mA, 150–199 mA, > 200 mA and unknown.
A total of 4998 patient records, comprising a combination of head, chest and abdomen CT scans, were assessed, with head CT scans representing nearly half of the total scans. Age-based adjusted CT protocols were observed in most of the scans with higher tube current setting being used with increasing age. However, a high tube current (150–199 mA) was still used in younger patients (0–8 years) undergoing head CT scans. In one hospital, CT protocols remained constant across all age groups, indicating potential overexposure to the patients.
This analysis shows that paediatric CT scans are adjusted according to the patient’s age in most of the routine CT examinations. This indicates increased awareness regarding radiation risks associated with CT. However, high tube current settings are still used in younger patient groups, thus, optimisation of paediatric CT protocols and implementation of current guidelines, such as age-and weight-based scanning, should be recommended in daily practice.
PMCID: PMC3432222  PMID: 22970059
Multislice CT; tube current; radiation; radiation risk; paediatric imaging
8.  Anatomical variations of pulmonary venous drainage in Thai people: multidetector CT study 
To evaluate the patterns of pulmonary venous drainage into the left atrium and to determine the frequency of each variant of pulmonary venous anatomy.
Materials and methods:
After institutional review board approval (No. 09JUL011148), 300 studies of thoracic multidetector computed tomography were retrospectively reviewed for the anatomical features of the pulmonary vein and its drainage pattern into the left atrium. The percentage of each pattern was calculated.
The anatomy of pulmonary venous drainage in 300 patients (150 male and 150 female, mean age 60.16 years) showed some variation. In the right pulmonary vein, the most common drainage pattern was two ostia (90.33%), followed by three to five ostia (6.33%) and a single ostium (3.33%). There were one or two separate middle lobe vein ostia in groups of more than two openings. On the left side, there were two patterns; a single venous ostium (59%) was much more common than two ostia (41%). In both right and left pulmonary veins, there were five cases (2 male, 3 female) that had a single pulmonary venous ostium, bilaterally. However, there were only 17 cases (5.67%), out of 300 enrolled in this study, that had bilateral pulmonary venous ostial variations.
A classification system to succinctly describe pulmonary venous drainage patterns was developed. In left-sided drainage, a single left pulmonary ostium was the most common variation. The right-sided venous drainage varied more in both number and pattern than those of the left side; nevertheless, bilateral pulmonary venous ostial variation was not frequently found.
PMCID: PMC3432223  PMID: 22970060
Multidetector CT; pulmonary vein; left atrium
9.  Dosimetric evaluation of radiation dose rate effect in respiratory gated intensity modulated radiation therapy† 
To investigate the dosimetric accuracy of the sliding window gated IMRT compared with the static treatment, using varying dose rates.
Materials and methods:
This study measured changes in output and diode array response with changing dose rate, verified the precision of the motion table, and measured changes in dose distribution accuracy with film and diodes at two depths with changing dose rate. During 4DCT (4 Dimensional Computed Tomography), the patient’s respiratory signals and target motion were recorded and imported to the XY4D simulation table of SUN NUCLEAR Corporation to simulate the patient’s respiration and tumour motion. A single field of each sliding window IMRT plan with 30º wedge and one for lung cancer were used in this study. Three irradiating conditions, static and moving target with and without gating, were applied to both plans.
The standard deviations of output, with the dose rates changing from 300–600 MU/min, were 0.065 cGy and 0.169 cGy for the ionisation chamber and diode, respectively. The verification of the motion table shows very good precision with 9.98 ± 0.02 cm (true value = 10.0 cm). The measurements by MapCheck show the gamma index of the planned absolute dose distribution in static and moving targets with gating, resulting in more than 96% passing for all dose rates. The absolute dose distribution measured by film for the static target was agreeable with the value of moving target with gating.
The sliding window gated IMRT technique is able to deliver an accurate dose to a moving target with the dose rate of 300–600 MU/min that is suitable for clinical treatment.
PMCID: PMC3432224  PMID: 22970061
Fine needle aspiration (FNA); pneumothorax; lung lesion; biopsy; CT
10.  Precocious puberty in children: A review of imaging findings 
This review was aimed at determining the imaging findings in patients with precocious puberty.
Within a period of 8 years (from 2002 to 2010) there were 53 patients diagnosed with precocious puberty. Out of the 53 patients, 37 had undergone diagnostic imaging to detect the possible organic causes of precocious puberty. Imaging findings were positive in 31 patients and out of that, 3 patients had 2 findings each (34 abnormalities). Of the patients with positive imaging findings, central precocious puberty (gonadotrophin-dependent) was more common (81%; 25/31) and the causes included: tuber cinereum hamartoma (n = 10), glioma (n = 6), pineal gland tumour (n = 4), hydrocephalous (n = 3), arachnoid cyst (n = 2) and others (n = 3). Peripheral precocious puberty (gonadotrophin-independent) causes included: testicular adrenal rest tumour (n = 3), adrenal carcinoma (n = 1), ovarian granulosa thecal cell tumour (n = 1), and tuberous sclerosis (n = 1).
Positive imaging findings were observed in 84% (31/37) of the subjects. Hypothalamic hamartoma was the most common imaging finding in central precocious puberty while testicular adrenal rest tumour was the most common imaging finding in peripheral precocious puberty.
PMCID: PMC3432225  PMID: 22970062
precocious puberty; imaging
11.  Congenital renal anomalies detected in adulthood 
To document the types of congenital renal anomalies detected in adulthood, the clinical presentation and complications of these renal anomalies, and the most useful imaging modality in detecting a renal anomaly.
Materials and methods
This study was approved by the institutional review board and informed consent was waived. Between January 2007 and January 2011, the clinical data and imaging studies of 28 patients older than 18 years diagnosed with renal anomaly at the authors’ institution were retrospectively reviewed. Renal anomalies in this study included only those with abnormality in position and in form.
Of these 28 patients, 22 underwent imaging studies and their results constituted the material of this study. Of the 22 patients, 14 had horseshoe kidneys (HSK), four had crossed renal ectopia and four had malrotation. Sixteen patients were men and six were women. The patients ranged in age from 19 to 74 years (mean age 51.1 years). Clinical presentations were abdominal pain (13), fever (13), haematuria (4), palpable mass (2), asymptomatic (2), polyuria (1) dysuria (1), blurred vision (1), and headache with weakness of left extremities (1). Imaging studies included abdominal radiograph (15), intravenous pyelography (IVP) (8), retrograde pyelography (RP) (4), ultrasonography (US) (7), and computed tomography (CT) (9). Associated complications included urinary tract stones (17), urinary tract infection (16), hydronephrosis (12), and tumours (2). Abdominal radiograph suggested renal anomalies in nine out of 15 studies. IVP, RP, US and CT suggested anomalies in all patients who had these studies performed. However, CT was the best imaging modality to evaluate anatomy, function and complications of patients with renal anomalies.
HSK was the most common renal anomaly, with abdominal pain and fever being the most common presentations. UTI and stones were the most common complications. IVP, RP, US and CT can be used to diagnose renal anomalies but CT is the best imaging modality to evaluate renal anatomy, function and its complications.
PMCID: PMC3432226  PMID: 22970063
renal anomalies; horseshoe kidney; crossed renal ectopia; malrotation; ultrasound
12.  Dialysis catheter fibrin sheath stripping: a useful technique after failed catheter exchange 
Fibrin sheath formation around long-term haemodialysis catheter is a common cause of failed dialysis access. Treatment options include pharmacological and mechanical methods. This paper reports a case of failed dialysis access due to fibrin sheath encasement. Pharmacologic thrombolysis, mechanical disruption using guide wire and catheter exchange had failed to address the issue. Eventually, fibrin sheath stripping using the loop snare technique was able to successfully restore the catheter function.
PMCID: PMC3432227  PMID: 22970064
Fine needle aspiration(FNA); pneumothorax; lung lesion; biopsy; CT
13.  Social radiology: Where to now? 
Radiology is a relatively high-cost and high-maintenance aspect of medicine. Expertise is constantly required, from acquisition to its use and quality assurance programmes. However, it is an integral part of healthcare practice, from disease diagnosis, surveillance and prevention to treatment monitoring. It is alarming that two thirds of the world is deficient in or lacks even basic diagnostic imaging. Developing and underdeveloped countries need help in improving medical imaging. Help is coming from various organisations, which are extending hands-on teaching and imparting knowledge, as well as training trainers to increase the pool of skilled practitioners in the use of imaging equipment and other aspects of radiology services. The scene for social radiology is changing and set to positively impact the world in the (near) future.
PMCID: PMC3432228  PMID: 22970065
Radiology services; diagnostic imaging; social radiology; radiation protection and safety; outreach programmes; developing countries
14.  Pelvic aneurysmal bone cyst 
This paper describes an extremely rare case of a huge aneurysmal bone cyst (ABC) in the pelvis, occurring in the patient’s 5th decade of life. The patient presented with a history of painless huge pelvic mass for 10 years. Plain radiograph and computed tomography showed huge expansile lytic lesion arising from the right iliac bone. A biopsy was performed and histology confirmed diagnosis of aneurysmal bone cyst. Unfortunately, the patient succumbed to profuse bleeding from the tumour.
PMCID: PMC3265184  PMID: 22279501
Aneurysmal bone cyst; Ilium; Pelvic bone
15.  A phase II study of oxaliplatin with 5-FU/folinic acid and concomitant radiotherapy as a preoperative treatment in patients with locally advanced rectal cancer† 
To evaluate the activity and safety of adding oxaliplatin to a standard chemoradiotherapy schema, including 5-fluorouracil (5-FU)/folinic acid (FA), in locally-advanced rectal cancer (LARC).
Two cycles of oxaliplatin 130 mg/m2 plus FA 20 mg/m2 bolus for 5 days and 5-FU 350 mg/m2 continuous infusion for 5 days were given during week 1 and 4 of pelvic radiotherapy 46 Gy. Patients with a T3/4 and/or node-positive rectal tumour were eligible. Surgery was performed 4–6 weeks after radiotherapy. The primary endpoint was to determine the rate of pathological response. Secondary endpoints were to assess the rate of clinical response and the safety profile.
Between March 2005 and January 2009, a total of 35 patients were enrolled. The pathological down-staging rate was 79% with a pathological complete response rate of 17%. The overall clinical response rate (assessed by computed tomography or transrectal ultrasound) was 77%. Grade 3 diarrhoea and Grade 3 neutropaenia were reported in 14% and 11% of the patients, respectively. Eleven patients did not undergo surgery: four of them refused the operation, and seven patients were inoperable due to disease progression. In 24 patients who had surgery, a sphincter-preserving procedure could be performed in 29%. At the median follow-up time of 28.1 months, 25 patients (71%) survived with no evidence of disease.
The promising results in terms of pathological response, and the associated good safety profile of a regimen of oxaliplatin plus 5-FU/FA with concomitant radiotherapy, suggest that the regimen could be used in LARC.
PMCID: PMC3265185  PMID: 22279502
5-fluorouracil; folinic acid; oxaliplatin; chemoradiotherapy; phase II study; advanced rectal cancer
16.  Epidural haemorrhage during embolisation: a rare complication of intra-arterial embolisation of vertebral metastases 
Pre-operative embolisation of vertebral metastases has been known to effectively devascularise hypervascular vertebral tumours and to reduce intra-operative bleeding. However, the complications that occur during the procedure are rarely reported. This case study attempts to highlight one rare complication, which is epidural tumoural haemorrhage intra-procedure. It may occur due to the fragility of the tumour and presence of neovascularisation. A small arterial dissection may also have occurred due to a slightly higher pressure exerted during injection of embolising agent. Haemostasis was secured via injection of Histoacryl into the area of haemorrhage. The patient was able to undergo the decompression surgery and suffered no direct complication from the haemorrhage.
PMCID: PMC3265186  PMID: 22279503
embolisation; metastasis; complications
17.  Ultrasound evaluation of penile fractures 
This short case report discusses the various aspects of penile fracture, which is a rare entity. Nevertheless, the incidence of penile fractures is on the rise due to the increased use of performance-enhancing drugs. An individual with a penile fracture should seek immediate medical referral. Prompt diagnosis and management is necessary to prevent undesirable after-effects as discussed. Emphasis is made on how imaging with ultrasound enables a quick and complete assessment of this mishap.
PMCID: PMC3265187  PMID: 22279504
Penile fracture; ultrasound; penile trauma
18.  Modified teaching approach for an enhanced medical physics graduate education experience 
Lecture-based teaching promotes a passive interaction with students. Opportunities to modify this format are available to enhance the overall learning experience for both students and instructors. The description for a discussion-based learning format is presented as it applies to a graduate curriculum with technical (formal mathematical derivation) topics. The presented hybrid method involves several techniques, including problem-based learning, modeling, and online lectures, eliminating didactic lectures. The results from an end-of-course evaluation show that the students appear to prefer the modified format over the more traditional methodology of “lecture only” contact time. These results are motivation for further refinement and continued implementation of the described methodology in the current course and potentially other courses within the department graduate curriculum.
PMCID: PMC3265188  PMID: 22279505
Medical physics education; guided discussion; problem based learning
19.  Radiological emergencies and the medical physicist† 
PMCID: PMC3265189  PMID: 22279506
21.  Lymphangioma: Is intralesional bleomycin sclerotherapy effective? 
This study aims to evaluate the effectiveness of intralesional bleomycin sclerotherapy in the treatment of lymphangioma in children and to determine the incidence of complications in the treatment.
This is a retrospective study of 24 children diagnosed with lymphangioma and treated with intralesional injection of bleomycin aqueous solution from January 1999 to December 2004.
Complete resolution was seen in 63% (15/24) of lesions, 21% (5/24) had good response and 16% (4/24) had poor response. The tumour recurred in 2 patients. Two other patients had abscess formation at the site of injection. No other serious complications or side effects were observed.
Intralesional bleomycin therapy was very effective in the treatment of lymphangioma. Our results were comparable to other published studies. Bleomycin administered as intralesional injection was found to be safe as there was no serious complication or side effect observed in this study.
PMCID: PMC3265190  PMID: 22279495
Lymphangioma; sclerotherapy; bleomycin
22.  Cotton-ball granuloma mimicking axillary lymphadenopathy in a breast cancer patient 
Foreign body granuloma is a reaction to either a biodegradable substance or inert material. In a breast cancer patient who had undergone an excision or mastectomy with axillary clearance, a foreign body granuloma in the axilla may be misinterpreted as an axillary lymph node. We report our experience with a case of cotton-ball granuloma of the axilla in a breast cancer patient, which mimics a lymph node radiologically from the CT scan, mammogram and ultrasonography. Following biopsy and excision, the mass was diagnosed histologically as a foreign body granuloma.
PMCID: PMC3265191  PMID: 22279496
Foreign body granuloma; cotton-ball; axillary lymphadenopathy; breast cancer
23.  Evaluating the clinical teaching of medical imaging students at Curtin University of Technology, Australia 
To ascertain the effectiveness of the clinical, tutorial-based component of teaching and the clinical assessment method in the Bachelor of Medical Imaging Science at Curtin University of Technology (CUT), Perth, Western Australia.
Materials and Methods:
In mid-2006, second- and third-year students enrolled in CUT’s Medical Imaging Science degree were asked to complete a questionnaire assessing the Objective Structured Clinical Examination (OSCE) evaluation program and clinical teaching. Thirty-three of 57 students answered questions about demographics and their opinions of the laboratory sessions, clinical placements and the OSCEs.
Seventy-six per cent of students were satisfied with their laboratory sessions and clinical placements. Sixty-four percent of respondents indicated that the OSCE was not an objective evaluation, but 82% of students felt the OSCE was an effective test of their radiography skills and knowledge, and believed that they were able to evaluate and care for a patient during the OSCE.
Overall, the surveyed students believed that the practical skills explored in laboratory sessions helped improve clinical training outcomes; however, only 33% of the students were satisfied that the OSCE was an appropriate assessment of their clinical training in hospitals.
PMCID: PMC3265192  PMID: 22279497
OSCE; clinical program; laboratory sessions; medical imaging education
25.  Evaluation of radiation dose to patients undergoing interventional radiology procedures at Ramathibodi Hospital, Thailand 
This study was carried out to assess the radiation dose to patients undergoing interventional radiology procedures at Ramathibodi Hospital, Bangkok, Thailand.
Data were collected from 60 patients under transarterial oily-chemoembolisation (TOCE) and femoral angiography performed with the Toshiba Infinix model VC-i FPD single plane system. Data were also collected from 60 patients who underwent brain arteriovenous malformations (AVM) and dural-arteriovenous fistula (DAVF) embolisation, performed with the Toshiba Infinix model VF-i bi-plane systems. A built-in air kerma area product (KAP) meter calibrated in situ was used for the skin dose calculation.
The calibration coefficient of air kerma area product meter at tube voltage between 50 kV and 100 kV was found to vary within ± 5.07%, ± 7.2%, ± 4.86 % from calibration coefficient of 80 kV for a single-plane, tube 1 and tube 2 of bi-plane x-ray system, respectively. Mean air kerma area product values were 90.99 ± 52.89, 31.02 ± 17.92, 33.11 ± 23.99 (Frontal), 35.01 ± 19.10 (Lateral), 50.15 ± 44.76 (Frontal), 97.31 ± 44.12 (Lateral) Gy-cm2 for transarterial oily-chemoembolisation, femoral angiography, diagnostic cerebral angiography, therapeutic cerebral angiography, respectively. The therapeutic cerebral angiography procedure was found to give the highest entrance dose, number of images and fluoroscopy time: 362.63 cGy (Lateral), 1015 images (Lateral) and 126 minutes, respectively. However, the highest air kerma area product value was from transarterial oily-chemoembolisation with 264.37 Gy-cm2. There were 2 cases of therapeutic cerebral angiography, where the patient entrance dose was higher than 3 Gy in the frontal view, which reached the deterministic threshold for temporary epilation.
Very wide variationswere found in patient dose from different interventional procedures. There is a need for a dose record system to provide feedback to radiologists who perform the procedures; especially in cases where the dose exceeds the deterministic threshold.
PMCID: PMC3265194  PMID: 22279499
Radiation doses; Patient doses; Air Kerma Area Product (KAP); Entrance dose; Interventional Radiology

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